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Charter Vessel Program Application for SIX Passenger Charter Vessels

Insured Information

Name of Insured (as will read on the policy):*

Owner's Name:*

Effective Date:*

Corporate Name (If any):

Is Corporation for sole purpose of ownership of vessel?

Yes

No

If no; explain:

Address, City, State:*

Phone: Home:

Bus:

Email*

Present Insurer:

Expiration Date:*

Prior Vessels Owned or Operated:

Year

Type

Length

How Long Owned

Year

Type

Length

How Long Owned

Year

Type

Length

How Long Owned

Losses in past 5 years? (on any vessel):

Yes

No

If yes, please list date, type, amount and status.

Hull Claims:

P&I Claims:

Vessel Information

Vessel Name:*

Year:*

Make:*

Model:*

Length:

Construction:

Steel

Fiberglass

Wood

Aluminium

Other:

Hull ID/Serial #:

Replacement Cost:

Has vessel been Coast Guard Inspected:

Yes

No

If yes, how many passengers is it certified for:

Doc. #:

Is vessel more than 6 passenger:

Yes

No

Date of Vessel's Last Survey:

Surveyed by whom:

Purchase Date: (MM/DD/YY)*

Purchase Price:*

Amount Financed:

Loss Payee:

Address:*

COVERAGES

Hull

Hull LIMIT

Hull DEDUCTIBLE

Hull PREMIUM

Trailers

Trailers LIMIT

Trailers DEDUCTIBLE

Trailers PREMIUM

Personal Effects

Personal Effects LIMIT

Personal Effects DEDUCTIBLE

Personal Effects PREMIUM

P&I

P&I LIMIT

P&I DEDUCTIBLE

P&I PREMIUM

Towing

Towing LIMIT

Towing DEDUCTIBLE

Towing PREMIUM

U/B

U/B LIMIT

U/B DEDUCTIBLE

U/B PREMIUM

Fuel Spill Liability

Fuel Spill Liability LIMIT

Fuel Spill Liability DEDUCTIBLE

Fuel Spill Liability PREMIUM

Med Pay

Med Pay LIMIT

Med Pay DEDUCTIBLE

Med Pay PREMIUM

You understand and agree this application is a request for a quote based on the information provided herein. You understand and agree the actual coverage, terms and conditions offered by MPG may be different than your request contained herein. The actual terms and conditions for coverage provided are represented by the policies issued and supersede any request or representations made prior to issuance.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

The applicant represents that the above statements and facts are true and that no material facts have been suppressed or misstated.

Applicant's Signature:

Date*

Print Name:*

Title:

Charter Vessel Program Application for SIX Passenger Charter Vessels

Insured Information

Prior Vessels Owned or Operated:

If yes, please list date, type, amount and status.

Vessel Information

ENGINE INFORMATION

NAVIGATION DETAILS

CAPTAIN INFORMATION

COVERAGES

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